MDPH Emergency Contraception Dispensing Annual Report
MGL c. 94C, § 19(A)(d)

For use by community pharmacies participating in the Massachusetts Pharmacy Access Program
By August 1st of each year, all community pharmacies participating in the Massachusetts (MA) Pharmacy Access Program must report to the Massachusetts Department of Public Health (MDPH) the total number of emergency contraception (EC) units of use dispensed pursuant to a Standing Order for the annual period from July 1–June 30 of the prior year. This completed report must be submitted to MDPH by:
•	fax to 617-624-6062, attn: MDPH Family Planning Program, or
•	email (as an attachment) to pharmacy.dph-ec@state.ma.us    
1. Name of pharmacy/chain:
•	Address Line 1:
•	Address Line 2:
•	City/Town/Zip Code:
•	Fax Number:
•	If Retail Pharmacy: enter Pharmacy License (Permit) No. (Pharmacy Board):
•	If Hospital/Clinic Pharmacy: enter Controlled Substance Registration No. (DCP):

2. Name of authorized pharmacy representative submitting report:
•	Name:
•	Title:
•	Email Phone Number:

3. For the annual period from July 1 to June 30, 20 _________ , the total number of units of use of EC (for example, Plan B® One-Step, Take ActionTM, or ella®) dispensed pursuant to a standing order was: ___________________ .

4. As of the date of this report, is there currently a specially trained pharmacist at this pharmacy authorized to dispense EC under a standing order for the next annual period? (please check one): 
YES       
NO
5. Do you need more information or technical assistance to continue participating in this program (e.g. help to locate a physician to sign or renew a standing order)? (please check one): 
YES: please describe technical assistance needs: 
NO
6. Would you benefit from informational materials to advertise this program (e.g. patient pocket guides, posters or product display cards for pharmacy aisle)? (please check one): 
YES: please describe materials needs: 
NO
Thank you for ensuring access to EC at your pharmacy!
For more information or technical assistance, please visit www.mass.gov/emergencycontraception or contact the MDPH Family Planning Program at 617-624-6060 or pharmacy.dph-ec@state.ma.us. 

Prepared by the Massachusetts Department of Public Health. Last revised July, 2015. Available online at www.mass.gov/emergencycontraception
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